Transcript Request Form - Southern State Community College

Office Use Only Date Sent___________ Staff_________________

Transcript Request Form

Today's Date_____________________

Name___________________________________________________________ Birth Date__________________________________________

Address________________________________________City____________________State_____________Zip________________________

ID# or SSN__________________________________________ Telephone Number (_____) ____________________________________

Transfer Module completed?

_____Yes

_____No

Are you a member of Phi Theta Kappa?

_____Yes

_____No

Have you taken EDUC 102or 1102, Found. of Education? _____Yes

_____No

If yes, do you need time sheets included with transcript?

_____Yes

_____No

SEND TRANSCRIPTS (Official Transcripts cannot be faxed):

______Immediately ______Hold until current semester grades posted (____________ Semester) ______Hold until Degree posted

Name or College:______________________________________________________________________________________________________ Attention:_____________________________________________________________________________________________________________ Street Address:________________________________________________________________________________________________________ City:________________________________________________State______________ Zip Code:_____________________________________

Name or College:______________________________________________________________________________________________________ Attention:_____________________________________________________________________________________________________________ Street Address:________________________________________________________________________________________________________ City:________________________________________________State______________ Zip Code:_____________________________________

____________________________________________________________

STUDENT'S SIGNATURE

Date

Mail requests to: Southern State Community College Attention: Records Office 100 Hobart Drive, Hillsboro, OH 45133 OR fax requests to (937) 393-6682

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